Provider Demographics
NPI:1497745814
Name:DICKENSON, RUSSELL ERIC (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:ERIC
Last Name:DICKENSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 PARKSIDE DR STE 331
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-1922
Mailing Address - Country:US
Mailing Address - Phone:865-392-3400
Mailing Address - Fax:865-392-3449
Practice Address - Street 1:10800 PARKSIDE DR STE 331
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37934-1922
Practice Address - Country:US
Practice Address - Phone:865-392-3400
Practice Address - Fax:865-392-3449
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN100363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3665210Medicaid
TN3665210Medicare PIN
970015460Medicare PIN
TNR60736Medicare UPIN
TN3665210Medicaid
TN103I976520Medicare PIN
TN103I970790Medicare PIN